Aida Ramic-Catak, Chapter III

Chapter III
RISK FACTORS FOR CARDIOVASCULAR DISEASES

AND PUBLIC HEALTH INTERVENTIONS,
PREVENTIONS AND CONTROL
Prof. Aida Ramić-Čatak MD, PhD
Introduction
Morbidity and mortality from cardiovascular diseases (CVD) is still the lead-
ing public health challenge worldwide. Although WHO data indicate the de-
cline in CVD mortality in the last few decades, there is still a lot of work to
be done by national health care systems on the way to a healthier commu-
nity. How quickly and successfully human lives will be saved from premature
death from CVD, and thus improve health and quality of life depends on
many internal and external factors in healthcare sector.
Key measures of internal healthcare sector are systematic approach to the
implementation of preventive measures on all levels of healthcare, available
diagnostics and therapy, and motivating people to adopt healthy lifestyle hab-
its. An integrated approach to prevention and control of CVDs is achieved
through combination of efficient pharmacological and non-pharmacological
treatments.
According to the professional literature, it has been confirmed that three
quarters of CVD cases and deaths are preventable, which is a fact that places a
special importance of public healthcare interventions. Cardiovascular disease
is most often caused by a combination of several different risk factors that we
can control such as diet, physical activity, obesity, smoking, high blood pres-
sure, high cholesterol, and diabetes.
To help member states, the World Health Organization (WHO) has adopt-
ed several relevant documents that should be used to develop national strate-
gies and action plans for the prevention and control of cardiovascular disease.
In 2012 the European Society of Cardiology (ECS) drew up guidelines for
cardiovascular risk management, which were reviewed in 2016, and in which
Cardiovascular diseases and oral health – the impact of pregnant women’s oral health on children’s cardiovascular health 29
CHAPTER III
recommendations were given to member states on the method for estimating

overall cardiovascular risk using SCORE table – the absolute 10-year risk
estimation of fatal CVD. With regard to presence of certain risk factors, the
10-year CVD mortality risk can be low, moderate, high and very high.
The European Society of Cardiology (ECS) guidelines on the use of the
SCORE method for CVD risk assessment are used and applied in Bosnia and
Herzegovina.
During 2017-2018 the project “Developing and Advancing Modern and
Sustainable Public Health Strategies, Capacities and Services to Improve
Population Health in Bosnia and Herzegovina” was developed and imple-
mented by the Entity Institutes of Public Health (Institute of Public Health
of the Federation of BiH, Public Health Institute of the Republic of Srpska),
in cooperation with the Ministry of Health of entities and the Department
for Health of Brčko District, and in cooperation with the WHO Office in
Bosnia and Herzegovina, which was jointly supported by the Swiss Agency
for Development and Cooperation (SDC) and World Health Organization
(WHO).
Within component 2 of the Project entitled: Adaptation/development of
instruments, materials and indicators sets for implementing, monitoring, and
evaluating interventions in the field of cardiovascular risk assessment and
management (CVRAM), guidelines for prevention and control of CVD risk
factors were published, intended for Family Medicine Teams in the Federation
of BiH, Republic of Srpska and Brčko District.
Like its neighboring countries, Bosnia and Herzegovina has high CVD
morbidity and mortality rate which is closely related to the exposure and
combined effects of multiple risk factors related to people’s habits and life-
style and the way they use health services.
In order to reduce CVD mortality rate in Bosnia and Herzegovina it is
necessary to further strengthen preventative systemic measures and control
risk factors in health sector, which should be supported by intersectoral inter-
ventions to promote health and motivate community to change their lifestyle
and health-related choices.
Cardiovascular disease as a global and regional challenge

Cardiovascular diseases are the leading cause of death globally even though
research shows that 80% of premature death from CVD is preventable by
30 Cardiovascular diseases and oral health – the impact of pregnant women’s oral health on children’s cardiovascular health
RISK FACTORS FOR CARDIOVASCULAR DISEASES AND PUBLIC HEALTH INTERVENTIONS,...
controlling leading risk factors such as smoking, unhealthy diet and physical
inactivity.
According to the data provided by the World Health Organization (WHO),
cardiovascular diseases (CVD) account for 17.9 million deaths annually, which
accounts for 31% of the total number of deaths globally. Cardiovascular diseases
are equally represented in both sexes which relates to their lifestyle and risk fac-
tors. The only difference is recorded between countries in terms of the organiza-
tion of healthcare system and availability of preventative healthcare, with 80%
of CVD mortality occurring in low- and middle-income countries. (1)
According to the WHO, cardiovascular diseases are a group of disorders
of the heart and blood vessels including coronary heart disease, cerebrovas-
cular disease, peripheral arterial disease, rheumatic heart disease, congenital
heart disease, deep vein thrombosis and pulmonary embolism. (1–3).
Risk factors for the development of cardiovascular diseases

There are many proven risk factors associated with the development of coro-
nary heart disease and stroke. Most authors distinguish between modifiable,
non-modifiable and other CVD risk factors. Cardiovascular diseases are rare-
ly caused by the action of one single risk factor. It is most often caused by the
combination of different risk factors, with certain combinations of risk factors
increase the overall mortality and morbidity risk more than others.
Exposure to single risk factor does not automatically mean the develop-
ment of CVD, but presence of several risk factors, which is usually the case,
increases the chances of CVD morbidity and mortality if necessary measures
are not taken to change patient’s behavior followed by interventions of suit-
able therapy and monitoring. (4,5)
CVD mortality rate could be significantly reduced by a systemic approach
to lifestyle changes and proper healthcare use. Reducing the cardiovascular
risk of the population by just 1% would prevent approximately 25 000 new
cases of cardiovascular diseases. The last three decades have seen a global de-
cline in CVD mortality rate for more than half which is attributed to the shift
in population levels of cholesterol, blood pressure and smoking. However,
this favorable trend has been partially offset by an increase in other risk fac-
tors, mainly obesity and type 2 diabetes mellitus. (4)
American Heart Association (AHA) defines factors for assessing cardio-
vascular health and determining cardiovascular risk. Risk factors are grouped
into modifiable, which you can changed throughout the course of life, and
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non-modifiable which one should know and keep under supervision and con-
trol. (5)
Modifiable CVD risk factors:

• physical inactivity,
• smoking,
• alcohol abuse,
• unhealthy diet,
• high blood cholesterol,
• high blood pressure/hypertension,
• obesity and overweight.
Physical inactivity
Lack of physical activity increases the risk for developing many diseases such
as diabetes, malignant neoplasms, osteoporosis, and cardiovascular diseases.
In fact, lack of physical activity has a negative effect on the CVD mortal-
ity, regardless of age, gender, and the presence of underlying cardiovascular
disease or not. Results of recently conducted meta-analysis of 36 prospective
studies on over 3 million participants during a period of 12 years showed that
implementing WHO recommendations on regular physical activity decreased
CVD mortality by 17%. (6)
Smoking
Smoking is the most important preventable cause of death globally and modi-
fiable risk factor for development of CVD. Smoking leads to a wide range
of diseases and disorders and is associated with 50% of preventable diseases
globally, half of which are CVD. Smokers are at twice the risk of developing
CVD than are non-smokers, and that risk increases with the number of ciga-
rettes smoked per day and duration of use. It has been proven that nonsmok-
ers who are exposed to secondhand smoke increase their risk of developing
CVD by 30%. (7)
The risk of developing coronary heart disease increases 6-fold in women
and 3-fold in men who smoke an average of 20 cigarettes per day compared to
people who never smoked. The risk of coronary heart disease increases with
the number of cigarettes smoked per day. The risk of recurrent heart attack is
reduced by 50% following cessation and is equalized with the risk of a non-
smoker within two years. (8)
Harmful chemicals in cigarette smoke significantly accelerate the devel-

opment of atherosclerosis. Various studies have found that carbon monoxide
(CO) and nicotine effects blood vessels. Hemoglobin binds carbon monox-
ide 245 times easier than with oxygen, resulting the formation of carboxy-
hemoglobin. The inability to transport oxygen causes hypotension of vascu-
lar endothelium and faster buildup of fatty plaques and atheroma formation.
Ingredients of tobacco smoke cause and increase in blood pressure, heart rate,
increase in adhesion and platelet aggregation, increase in blood carboxy-
hemoglobin concentration and atheroma formation, increase in free fatty ac-
ids concentration, serum total cholesterol and LDL cholesterol, reduces HDL
cholesterol and increase fibrinogen concentration. One year after smoking
cessation, CVD risk is reduced by 50%, and within 15 years the risk declines
to the level of a non-smokers. (9)
Alcohol abuse
Several studies show that moderate drinking is cardioprotective, based on
which the consumption of alcohol should be limited to 20g of alcohol per
day for men (2dcl of wine/day), and 10g of alcohol per day for women 1dcl
of wine/day). This amount is slightly lower for women due to variations in
enzymes involved in alcohol metabolism.
However, it should be emphasized that alcohol use affects cardiovascu-
lar system by increasing systolic and diastolic blood pressure, speeds up the
pulse, has an arrhythmogenic effect on the heart, and in some people raises
HDL cholesterol and triglycerides. When consumed in excess, alcohol con-
tains a lot of calories, approximately 7 kcal/g which are called “empty calo-
ries” because of the lack of the essential nutrients (vitamins, minerals, essen-
tial amino acids) which is something one should consider in order to prevent
and control excessive weight. (10).
Unhealthy diet
Term “faulty diet” implies inadequate energy value intake of food, the incor-
rect methods of food preparation and meal timing. Especially problematic
nowadays are “modern” habits of fast food and energy intensive food con-
sumption. Unhealthy diet contributes to the development of atherosclerosis,
arterial hypertension, ischemic heart disease, cerebrovascular stroke, heart
failure, obesity, dyslipidemia, type 2 diabetes, and various forms of malignant
neoplasms and many other diseases. Unhealthy eating habits including the
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excessive intake of salt, fats, sugar, cured meat and red meat, and insufficient
intake of vegetables and fruits, white meat, and fish, are responsible for more
than 20% of cardiovascular diseases globally. (11, 12)
High blood cholesterol

Increased cholesterol levels are associated with the third of all heart and blood
vessel diseases and strokes globally. Cholesterol includes HDL (“good”) cho-
lesterol, LDL (“bad”) cholesterol and high triglycerides. Lipids, especially
cholesterol and triglycerides, are substances that are insoluble in water and
are bound to certain big proteins, thus forming lipoproteins that are used to
transport them into blood. Protein component is called apolipoproteins or
apoprotein.
In dyslipoproteinemia, risk factors for coronary heart disease include
level of total and LDL cholesterol in blood, low level of HDL cholesterol,
increased total to HDL cholesterol ratio and hypertriglyceridemia. According
to some research, dyslipidemia accounts to 49%. (13)
High blood pressure – hypertension

High blood pressure is the most important risk factor for stroke and leading
cause of half of all diseases. According to INTERHEART study, high blood
pressure represents 18% of attributable risk for development of first myocar-
dial infraction. Systolic and diastolic blood pressure are equally important in
the development of coronary heart disease, and isolated systolic hypertension
is one of the main risk factors for the development of cardiovascular and cere-
brovascular events. Elevated vascular tone, which is a result of hypertension,
can lead to endothelial dysfunction, and thus to the release of vasoconstrictive
and thrombogenic factors and lead to acute or chronic coronary heart disease.
It is of utmost importance to monitor and control hypertension in patients
with pre-existing coronary heart disease. Epidemiological studies show that
the risk of developing cardiovascular disease rapidly increases with an in-
crease in pressure above 110/75 mmHg, similar as in patients with already
developed coronary heart disease. (14, 15).
Obesity and overweight

Obesity and being overweight raises the risk of high blood pressure, diabetes
and blockage of blood vessels.
Regular control of the body mass index (BMI) (the ratio of body weight
in kilograms and the square of height in meters, kg/m2) is important A BMI
of 18,5–24,9 shows that a person has an average level of health risk for the
development of obesity. On the other hand, a BMI of 25 and higher indicates
that a person has increased health risk for the development of obesity. (11)
In addition to the increased body weight, a significant risk factor is ab-
dominal obesity, measured by waist circumference. Values greater than 94
cm and 80 cm for men and women respectively represent a health risk, while
values greater than 102 cm and 88 cm for men and women respectively rep-
resent a very high health risk.
Non-modifiable risk factors

Family history – if a family member (parents, siblings) develops heart dis-
ease before the age of 55 in males and before the age of 65 in females, the risk
of developing CVD increases.
Age – the risk of developing CVD every decade after age 55, especially if
combined with some of the modifiable risk factors.
Gender – men have a higher risk of developing CVD than women who
have not yet entered menopause. After entering menopause, this risk is the
same for women. The risk for stroke is the same for both men and wom-
en. According to some research, the total cardiovascular risk, both fatal and
non-fatal CVD events, is three times higher than the risk of fatal CVD event
(SCORE) in men. The risk of fatal CVD event in women is four times higher
and in elderly people, who are more likely to die from the first cardiac event,
the risk is approximately three times higher. (13).
Diabetes
Insulin resistance, hyperinsulinemia, and elevated glucose levels have been
associated with coronary heart disease. People with diabetes are twice as
likely to have heart disease than people without diabetes. According to the
Copenhagen City Heart Study, relative risk of having an incident myocar-
dial infarction or stroke is increased 2- to 3-fold in persons with diabetes
type 2, and the risk of death is increased 2-fold, independent of other known
risk factors for cardiovascular diseases. (16) According to the results of
INTERHEART study, there is a 10% attributive risk of developing the first
myocardial infarction in people with diabetes. Patients with diabetes often
have other diseases that are associated risk factors for coronary heart disease,
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such as obesity, hypertension, hyperlipoproteinemia, and elevated fibrinogen

levels. (16, 17)
Other risk factors

Socioeconomic status – lower socioeconomic status (poverty) and social ex-
clusion are associated with an increased risk of cardiovascular diseases and
stoke. (12, 13)
Chronic stress
Long-term exposure to stressful situations has a negative effect on multiple
organ systems (vascular, nervous, immune, etc.). Numerous studies have
shown the connection between stress and increased frequency of CVD, but
there are differing opinions on the pathogenesis of this process and connection
with the development of CVD. Certain research suggests that chronic stress
can lead to an increase in blood pressure, heart arrhythmia and an increase in
frequency, an increase in fibrinogen and circulating levels of inflammatory
cytokines. Stress reduces the blood flow to the heart, which can cause the
heart to malfunction, increasing the tendency for blood clots to form. People
under chronic stress who have more frequent acute elevated blood pressure
have higher risk of developing arterial hypertension, and other CVD. (18)
Prevention of cardiovascular diseases (CVD)

Prevention is a process aimed at helping people cope with life’s necessities in
order to avoid behaviors that could lead to negative physical, psychosocial,
or social consequences on health, and do so through expansion of knowledge,
competencies and skills, and support systems in family, school, workplace
and healthy community environment. (19)
Prevention science developed by strengthening the preventive approach
in healthcare, which is defined according to various authors as: “Knowledge
broadening and interventions on prevention influenced the formulation of
prevention as a separate discipline” (Coie, 1993), or as: “Multidisciplinary
science that encompasses medicine, psychology, sociology, political science,
social work, economics, marketing” (Durlak, 1997) or ”Identification of risk
factors that influence prevalence of certain diseases and disorders, and estab-
lishing community-based prevention systems” (Hawkins, 2001).
Prevention of CVD is defined as a coordinated pool of activity at the

population level or individual level with the aim of eliminating or reducing to
the lowest level of CVD incidence and their consequences. (20)
Prevention is traditionally divided into primary, secondary, and tertiary
prevention which is largely applicable in the case of CVD.
Primary prevention is based on efficient prevention of disease before any
significant health damages were done and is based on health promotion and
disease prevention. It is a set of activities aimed at eliminating or reducing
risk factor exposure at individual and population level, before CVD develops,
i.e., reducing the exposure to single and/or combined risk factors by motivat-
ing lifestyle change.
Foundation of primary prevention of CVD at individual level should in-
clude avoiding risk factors and lifestyle changes by having healthy eating
habits and healthy diet, cessation of smoking and alcohol use, and regular
physical activity. Primary prevention of CVD at population level should be
done by promoting healthy community lifestyle, informing and educating the
population. (21)
Secondary prevention is activities aimed at early identification of health
problems in individuals and population. It is based on early treatment and pre-
vention of CVD consequences. The aim of these activities is early diagnosis
at the presymptomatic stage of disease by focusing on reducing inequalities
in access to health care services. (21)
Experience shows that a combination of population-wide and individual
approach is the most effective approach for CVD prevention, whereby popu-
lation-wide approach is aimed at people with low or moderate level of CVD
risk, and individual approach is aimed at people with high level of CVD risk.
In the context of CVD, the difference between primary and secondary pre-
vention is not clearly formulated due to the synergistic effect of all measures
aimed at the same goal – education on modifiable risk factors has positive ef-
fect on disease prevention in healthy population and a milder disease progress
in patients with diagnosed CVD. (22)
Tertiary prevention is a set of activities aimed at reducing the effects of
CVD, premature death and disability.
Investing in prevention is an investment in the health of the population,
which has been confirmed and stated in the literature according to which
elimination of risk factors, including unhealthy lifestyle, allows for preven-
tion of at least 80% of CVD mortality and morbidity cases (22-24)
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European Society of Cardiology (ESC) defines prevention of cardiovas-

cular disease as: “A coordinated set of actions, at the population level or tar-
geted at an individual, which are aimed at eradicating, eliminating or mini-
mizing the impact of CVDs and their related disabilities.” (25, 26)
Preventative and therapeutic interventions of CVD at individual

level
According to European Society of Cardiology ECS, basic guidelines for
intervention and prevention goals of CVD should focus on regular control,
early diagnosis, monitoring, and treatment of key CVD risk factors. (25, 26)
(Table 1)
Table 1. Prevention guidelines for CVD, ECS, 2016.
Risk factor Recommendation/intervention
Smoking Smoking cessation or using any tobacco products. No exposure to tobacco in any form.
Diet Healthy diet low in saturated fat with a focus on whole grain products, vegetables, fruit, and fish.
Physical activity At least 150 min moderately vigorously physical activity per week (30 min 5 days/per week) or 75
min intensive physical activity per week (15 min 5 day/per week) or combination.
Body weight BMI 20-25 kg/m². Waist circumference <94 cm (men) and <80 cm (women).
Blood pressure <140/90 mmHg. This BP is general goal. The BP target can be higher in older people, or lower in
most patient with type 2 diabetes mellitus and in some high-risk patients without diabetes who
can tolerate multiple antihypertensive drugs.
Lipids
LDL Very high-risk: LDL <1,8 mmol/l (70-135mg/dL) or a reduction of at least 50%.
High-risk: LDL <2,5 mmol/L (<100mg/dL) or a reduction of at least 50% (2,6–5,2 mmol/L).
Low to moderate risk: <3,0 mmol/L (<115 mg/dL).
HDL No target, but >1,0 mmol/L (>40 mg/dL) in men and >1,2 mmol/L (>45mg/dL) in women
indicates lower risk.
Triglyceride No target but < 1,7 mmol/L (<150 mg/dL) indicates lower risk and higher levels indicate a need to
look for other risk factors.
Diabetes HbA1c < 7%. (< 53 mmol/mol)
Source: Adapted according to ECS, 2016.
Systematic CVD risk assessment is recommended in people with high

CVD risk, such as positive family history of sudden and premature death,
familial hyperlipidemia, smoking, hypertension, diabetes mellitus or elevated
lipid levels, and/or comorbidities that increase CVD risk.
It is recommended to repeat CVD risk assessment every five years,

and even more often if the person has very high risk and requires medical
treatment.
Systematic CVD risk assessment should be considered in both adult men
>40 years of age and in women >50 years of age or postmenopausal without
known CVD risk factors. (25,26)
The 2016 ESC Guidelines formulate recommendations and healthy di-
etary energy balance in relation to diet as one of the most significant risk fac-
tors for development of CVD. (Table 2)
Tabela 2. Preporuke za zdravu ishranu, ECS, 2016. god.

Healthy Diet recommendations
Saturated fatty acids to account for <10% of total energy intake, through replacement by unsaturated fatty acids
As little trans unsaturated fatty acids as possible. No intake of processed foods preferable, <1% of total
energy intake of natural origin
<5 g of salt per day
30-45 g of fiber per day, from wholegrain products.
>200 g of fruit per day (2–3 servings)
>200 g of vegetables per day (2–3 servings)
30 g of unsalted nuts per day
Fish at least once or twice a week
Consumption of alcoholic beverages should be limited to 2 glasses per day (20 g/per day) for men and 1 glass per day
(10 g/per day) for women
Limited intake/avoid sugary nonalcoholic sodas
Source: Adapted according to ECS, 2016
Regarding the treatment of hypertension as one of the leading risk factors

for CVD, the 2016 ESC Guidelines define a therapeutic guidance for all con-
ditions that occur in comorbidity for cardiovascular risk. (25, 26) (Table 3)
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Table 3: Treatment protocol for conditions associated with hypertension, ECS, 2016
Condition/disease Therapy
Asymptomatic organ damage
LVH ACE-I, calcium antagonism, ARB
Asymptomatic atherosclerosis calcium antagonism, ACE-I
Microalbuminuria ACE-I, ARB
Renal failure ACE-I, ARB
CVD
Previous stroke Any effective BP lowering drug
Previous MI β-blockers, ACE-I, ARB
Angina pectoris β-blockers, calcium antagonism,
Heart failure diuretics, β- blockers, ACE-I, ARB, receptor antagonists
mineralokortikoida
Aortic aneurysm β-blockers,
Atrial fibrillation: prevention Consider ARB, ACE-I, β- blockers or mineralocorticoid-receptor
antagonists
Atrial fibrillation: rate control β-blockers, non-dihydropyridine calcium antagonists (Calcium
channel blockers)
ESRD/proteinuria ACE-I, ARB
Peripheral arterial disease ACE-I, calcium antagonism
Other conditions
ISH (older) diuretics, calcium antagonism,
Diabetes mellitus ACE-I, ARB
Pregnancy Methyldopa, β-blockers, calcium antagonism
ACE-I = angiotensin-converting enzyme inhibitor; ARBs = angiotensin receptor blockers; BP =blood
pressure; CV = cardiovascular; diuretics = thiazide and thiazide-like diuretics; ESRD = end-stage
renal disease; ISH = isolated systolic hypertension; LVH= left ventricular hypertrophy; MI =
myocardial infarction
According to the European Society of Cardiology (ESC), guidelines for

interventions and goals of CVD prevention should focus on regular assess-
ment, early diagnosis, monitoring and treatment of serum LDL levels. (25,
26) (Table 4)
Table 4: Recommendations for treatment of cardiovascular risk (SCORE) with regard to

serum concentration of LDL, ECS, 2016.
Concentration of LDL cholesterol (mmol/L)
Total CV risk (SCORE) %
< 1,8 1,8–2,49 2,5–3,99 4,0–4,89 >4,9
Lifestyle
change,
<1 No intervention No intervention No intervention No intervention
statin if no
progress
Lifestyle
Lifestyle Lifestyle
change,
>1 to <5 No intervention No intervention change, statin if change, statin if
statin if no
no progress no progress
progress
Lifestyle Lifestyle Lifestyle Lifestyle
>5 do <10 or very
No intervention change, statin if change, statin change, statin change,
high-risk
no progress at once at once statin at once
Lifestyle Lifestyle Lifestyle Lifestyle
Lifestyle change,
>10 or very high-risk change, statin change, statin change, statin change,
consider statin
at once at once at once statin at once
The ESC Guidelines for CVD prevention emphasize the importance of

achieving and maintaining target LDL cholesterol level according to the fol-
lowing SCORE risk categorization:
• Very high risk: LDL-C goal of <1,8 mmol/L or a reduction of at least 50%
if the baseline LDL-C is between 1,8 and 3,5 mmol/L.
• High risk: LDL-C goal of <2,6 mmol/L or a reduction of at least 50% if
the baseline LDL-C is between 2,6 and 5,2 mmol/L.
• Moderate or low risk: LDL-C goal of < 3,0 mmol/L.
Population-level CVD preventive interventions

Diet
Relevant WHO documentation of best practice recommend that governments
adopt appropriate legislative measures on food composition in order to re-
duce amount of salt, saturated fats, added sugars in food and beverages and
limit portion sizes. The elimination of industrially produced trans fatty acids
is recommended. A systematic approach to the policies and strategies of gov-
ernments, NGOs, food industry, trade, catering industry, schools, working
places and other stakeholders is recommended to promote healthy eating and
prevent overweight and obesity.
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Legislation restricting child-centered marketing is also recommended -

foods high in fat, sugar and/or salt, fast food, alcoholic beverages and non-
alcoholic sugar-sweetened beverages (e.g., on television, the Internet, social
media and on food packaging).
There are also important recommendations related to regulation of food
labeling, according to which mandatory and harmonized labeling of nutrients
is recommended.
As for economic measures, food pricing and subsidies are recommended
to promote healthier food and beverage choices and to pass laws on taxes on
foods and sugar-sweetened beverages and saturated fats, as well as alcoholic
beverages. (21–26)
Physical activity
In order to promote physical activity, it is recommended to increase equip-
ment availability and different types of school playgrounds and equipment
for exercise and sports, revise curriculum which would include more hours of
physical education classes and health education.
Adequate urban planning solutions are recommended in terms of better
accessibility of recreational facilities and facilities for physical activity (e.g.,
construction of parks and playgrounds, after-hours use of school facilities).
Popularization of physical activity through targeted media and education-
al campaigns using various dissemination channels.
As for economic measures, the increase of gasoline taxes to increase ac-
tive transport is recommended, tax incentives encouraging tax cuts for indi-
viduals to purchase exercise equipment or health club/fitness memberships,
as well as tax incentives to employers to offer comprehensive worksite well-
ness programs and healthy nutrition. (21–26)
Smoking
In order to protect the population from exposure to tobacco smoke, it is rec-
ommended to pass laws banning smoking and consumption of all types of
tobacco products in enclosed workplaces and public spaces, followed by ef-
fective inspections and sanctions.
Reducing the availability of tobacco products should be regulated by en-
acting laws banning sales and serving of all types of tobacco products to
persons under 18 years of age accompanied by effective inspections and
sanctions.
In order to eliminate tobacco advertising, it is recommended that a com-

prehensive ban on all tobacco advertising, promotion and sponsorship by the
tobacco industry is introduced.
Media and education campaigns aimed at smoking cessation are of the ut-
most importance since they prevent smoking and promote quitting and reduce
secondhand smoke exposure by promoting smoke-free spaces.
To motivate smoking cessation, it is necessary to increase the availability
of efficient and standardized smoking cessation services within the health-
care system, especially at the level of primary healthcare/family medicine
and public health. It is also recommended to introduce telephone and internet
lines for smoking cessation counseling and support services.
Adopting a law regulating the introduction of graphic and written warn-
ings on the outer packaging of all types of tobacco products.
As for economic measures, raising taxes on all tobacco products is recom-
mended since it is the most cost-effective solution for reducing tobacco use
among children and youth. (21–26)
Alcohol
Reduction in the availability of alcoholic beverages should be regulated by
a law banning the sale and service of all types of alcoholic beverages to ad-
olescents (under the age of 18), accompanied by effective inspections and
sanctions.
In order to eliminate the promotion of alcoholic tobacco products, it is
recommended to pass a law that introduces comprehensive ban on alcohol ad-
vertising and promotion, as well as sponsorship by alcohol drinks companies.
It is necessary to increase the availability of efficient and standardized
alcohol withdrawal services within the healthcare system.
Regarding economic measures, adopting laws and policies that allow
raising taxes on all alcoholic products is recommended since it is the most
cost-effective solution for reducing alcohol consumption among children and
youth. (21–26)
The WHO global action plan for CVD prevention and control
With the aim of achieving global response to CVD, WHO prepared a “Global
Action Plan for the Prevention and Control of Noncommunicable Diseases
2013-2020” in 2013 which was approved by WHO’s 194 member countries.
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This document is based on nine voluntary global targets, including the reduc-
tion of premature mortality attributed to NCD by 25% by 2025. (23)
Within the scope of WHO’s aim to reduce premature mortality to CVD by
25%, special attention is paid to individual risk factors. Thus, the sixth goal is
to reduce the global prevalence of arterial hypertension as one of the leading
risk factors by 25%.
WHO data shows that the global prevalence of hypertension in adult men
is 24.1% and 20.1% in women. Total number of adults with hypertension sig-
nificantly increased from 594 million in 1975 to 1.13 billion in 2015, with the
increase seen largely in low- and middle-income countries. (23)
Reducing arterial hypertension incidence is achieved through efficient
measures of early diagnosis, monitoring and treatment followed by popu-
lation-wide approach to reduction of behavioral risk factors such as alco-
hol consumption, physical inactivity, being overweight and obesity and salt
intake.
The eight goal mentioned in the “Global Action Plan for the Prevention
and Control of Noncommunicable Diseases 2013-2020” predicts that at least
50% of population is eligible to receive drug therapy and counselling (in-
cluding glycemic control). Prevention of heart attacks and strokes based on
an effective unique approach to CVD risk is much more cost-effective than
therapeutic measures which are based on individual risk factors and should be
covered by primary health care. Achieving this goal is based on strengthening
key components of the health care system, which include health care financ-
ing, ensuring access to health care services, and an essential medicine list for
chronic noncommunicable diseases. (23)
It is significant to mention that in 2012, a European Guidelines on
Cardiovascular Disease Prevention in Clinical Practice was published by
the European Association for Cardiovascular Prevention and Rehabilitation
(EACPR). It is based on the SCORE tables developed by WHO for calculat-
ing 10-year CVD morbidity and mortality based on age, sex, systolic blood
pressure (mm Hg) and total cholesterol (mmol/L). (24)
In 2016, WHO published ECS Guidelines on Cardiovascular Disease
Prevention which contained the updated version of CVD SCORE risk factor
tables for certain WHO regions. (25, 26)
With the aim of providing support to governments to implement effective
CVD control and prevention measures, the HEARTS Technical package was
developed in 2018 by WHO in conjunction with Global Hearts Initiative and
US Centers for Disease Control and Prevention which comprises of six mod-
ules and an implementation guide. (27)
HEARTS is technical package provides a set of six recommended and
effective interventions for strengthening the management of risk factors for
CVDs in primary health care (PHC) as follows:
1. Healthy lifestyle (smoking cessation, healthy diet, physical activity,
self-care)
2. Treatment protocols (procedures algorithms)
3. Access to health care (accessibility of health care services)
4. Health services management (diagnostics and control of risk factors)
5. Teamwork (decentralized, community-based care)
6. Systems for monitoring (patient data, medical documentation, program
evaluation)
Cardiovascular disease in Bosnia and Herzegovina

According to the data published by WHO country office for Bosnia and
Herzegovina, chronic non-communicable diseases accounted for 94% of all
deaths in 2016, out of which cardiovascular diseases accounted for 53%,
cancers for 19%, diabetes for 7%, chronic obstructive pulmonary diseases
(COPD) for 4%, 4% for injuries and 12% for other NCDs. Total premature
mortality rate from NCDs in Bosnia and Herzegovina in 2016 was 36.300, of
which 17.800 were men and 18.600 women. (28)
According to the same report, individual risk factors for CVD are sig-
nificant among population, of which the most common are: hypertension ac-
counts for 37% of the population, of which 38% men and 35% women, smok-
ing accounts for 38% of population aged 15 and over, of which 47% men and
29% women, diabetes in adults accounts for 9%, of which 10% men and 9%
women, physical inactivity accounts for 26%, and obesity accounts for 19%,
of which 18% men and 21% women. (28)
Exposure to risk factors is related to the continuing trend of increased
mortality rate from CVD in Bosnia and Herzegovina. According to the data
by WHO, in the period from 2000 to 2016, there was an increase in the num-
ber of deaths from cardiovascular diseases, from 17,774 in 2000 to 20,279 in
2016, with a higher mortality rate from CVD recorded in women compared
to men in each observed year. (29) (Table 5)
CHAPTER III
Table 5. CVD mortality rate in BiH in the period from 2000 to 2016
Year Total number of deaths Males Females
2000 17774 8614 9160
2005 19965 9652 10313
2010 20095 9318 10777
2015 20044 9235 10809
2016 200279 9298 10982
Source: WHO, 2017
Mortality rate from CVD in the Federation of Bosnia and

Herzegovina
Like the neighboring countries, cardiovascular diseases are the leading cause
of death in the Federation of Bosnia and Herzegovina, with recorded long-
term upward tendency of standardized death rate (SDR) from cardiovascular
diseases since 2010, and declining tendency in the period from 2016 to 2019.
(30) (Graph 1)
Graph 1: SDR from CVD per 100,000 persons,
Federation of Bosnia and Herzegovina, period from 2010 to 2019
Source: FBiH Public Health Institute, 2020
Based on the 2020 Report of the FBiH Public Health Institute on health
status of population and organization of healthcare institutions in 2019, the
leading cause death in FBiH are circulatory system diseases accounting for
47,9%. (30)
Leading cause of death is acute myocardial infraction (I20) with 97,0
deaths per 100.000 persons. Stroke (I63) is the second leading cause of death
with 91,0 deaths per 100.000 persons, and essential hypertension (I10) is on
the third place with 67,1 deaths per 100.000 persons, followed by chronic
ischemic heart disease (I25) with 51,7 deaths per 100.000 persons and cardio-
myopathy (I42) with 64,1 deaths per 100.000 persons. (30) (Graph 2)
Graph 2: Mortality rate from CVD per 100.000 persons in BiH,
period from 2017 to 2019
Leading cause of death for women in 2019 was stroke (I63) with 103,3
deaths per 100.000 persons, and the second most common cause of death
among women was essential hypertension (I10) with 79,3 deaths per 100.000
persons, followed by acute myocardial infarction (I21) with 75,4 deaths per
100.000 persons and chronic ischemic heart disease (I25) with 59,2 deaths
per 100.000 persons. (30) (Graph 3)
Graph 3: Five leading causes of death among women in FBiH in the period from 2017
to 2019, mortality rate per 100.000 persons
CHAPTER III
The leading cause of death among men is acute myocardial infarction

(I21), with 120,6 deaths per 100.000 persons, followed by stroke (I63), with
79,6 deaths per 100.000 persons, essential hypertension (I10), with 56,5
deaths per 100.000 persons and chronic ischemic heart disease (I25), with
44,9 deaths per 100.000 persons. (30) (Graph 4)
Graph 4: Five leading causes of death among men in FBiH in the period from 2017
to 2019, mortality rate per 100.000 persons
Source: Public Health Institute of the FBiH, 2020
Risk factors for development of CVD in the FBiH

According to the results of the study on Adult population health status in
FBiH implemented by FBiH Public Health Institute, the following risk fac-
tors for developing CVD among adults (31) are dominant:
• Hypertension: almost half of adults or 42,1% have hypertension and/or
are undergoing treatment in FBiH, of which 45,3% are men and 38,9% are
women.
• Obesity: almost a quarter or 21,2% of adults in FBiH is obese, of which
19,1% are men and 23,3% are women.
• Physical inactivity: only quarter of population or 24,6% in FBiH is physi-
cally active, of which 28,7% are men and 20,3% are women.
• Smoking: almost half of the adults or 44,1% are smokers in FBiH, of
whom 56,3% are men and 31,6 % are women. Over half of the population
or 54.1% is exposed to tobacco smoke daily by other smokers in their own
home, 44,4% in the workplace and 52,7% in a public place.
Smoking is a significant public health problem among school-aged chil-
dren and youth in FBiH. According to the results of Global Youth Tobacco
Survey (GYTS) implemented by the FBiH Public Health Institute in 2019,
almost quarter of school-aged children or 24,4% currently use some tobacco

products, 27,7% of boys, and 21,1% of girls. 13.8% of school-aged children,
15.8% of boys, and 11.7% of girls currently smoke cigarettes. The results of
this survey confirmed that smoking waterpipe represents a particular pub-
lic health challenge. According to this research, 16,1% of children, of which
17,7% are boys and 14,4% are girls currently smoke waterpipe. (32)
It is important to mention that smoking among health care professionals in
FBiH is widespread. According to the survey conducted by the FBiH Public
Health Institute in 2017, smoking among family medicine doctors and nurses
was 35% in FBiH. (33)
Prevention and control of CVD in Bosnia and Herzegovina
Republic of Srpska
Government of the Republic of Srpska in 2003 adopted Action Plan for
the Prevention and Control of Non-communicable Diseases at the proposal of
Ministry of Health and Social Welfare of the Republic of Srpska. (34)
Ministry of Health and Social Welfare of the Republic of Srpska also pub-
lished a significant number of clinical guidelines (34) for addressing cardio-
vascular diseases.
Clinical guidelines:
• acute myocardial infarction,
• angina pectoris,
• arterial hypertension,
• atrial fibrillation,
• diabetes mellitus,
• diabetes and cardiovascular disease,
• physical activity,
• obesity in children,
• obesity in adults,
• hyperlipoproteinemia,
• smoking cessation
Federation of Bosnia and Herzegovina

According to the Law on Healthcare in Federation of BiH, family med-
icine team within the primary health care (PHC) offers continuous and
CHAPTER III
comprehensive protection oriented at prevention, control and early diagnosis

of disorders and diseases. (35)
Law on Patient Rights and Responsibilities states rights of patients to be
informed and educated by healthcare professionals in terms of disease pre-
vention and health protection, as well as personal health responsibilities. (36)
Disease prevention and health promotion is a significant part of family
medicine specialization and additional continuing education training pro-
grams /PAT/ (Program for Additional Training) in family medicine. (37)
Agency for Quality and Accreditation in Healthcare (AKAZ) introduced
accreditation standards to Community Health Centers and family medicine
teams. Chapter 3 of this document lists activities for health promotion and
disease prevention. (38)
According to the Law on Healthcare in Federation of BiH, the basic func-
tions of public health are (35):
1) monitoring, evaluation and analysis of population health status;
2) surveillance, research, and control of the risks and threats to public health;
3) health promotion;
4) social participation in health;
5) development of policies and institutional capacity for public health plan-
ning and management;
6) strengthening of public health regulation and enforcement capacity;
7) strengthening of public health planning and management capacity;
8) evaluation and promotion of equitable access to necessary health services;
9) human resources development and training;
10) quality assurance in persona and population-based health services;
11) research in public health;
12) reduction of the impact of emergencies and disasters on health of the
population.
Regarding control and prevention of chronic non-communicable diseas-
es in FBiH, several strategic documents have been adopted by the Federal
Ministry of Health (39–47):
• Strategic Plan for Health Care Development in the Federation of Bosnia
and Herzegovina from 2008 to 2018,
• Strategic Plan of PHC Development in FBiH, 2008,
• Strategy for Prevention, Treatment and Control of Malignant Neoplasms
in FBiH, 2012–2020,
• Resolution on Diabetes, 2012,
• Policy for Improving Child Nutrition in FBiH, 2013,
• Policy and Strategy for Protection and Promotion of Mental Health in

FBiH, 2012–2020,
• Combat Diabetes in FBiH, 2014–2024,
• Law on Restricted Use of Tobacco, Tobacco and other Smoking Products,
2018 (Draft),
• Action Plan for Prevention and Control of Chronic Non-communicable
Diseases of FBiH from 2019 to 2025
Public health interventions in prevention and control of CVD

in Bosnia and Herzegovina
During the period from 2016 to 2018, the project “Developing and Advancing
Modern and Sustainable Public Health Strategies, Capacities and Services to
Improve Population Health in Bosnia and Herzegovina” was developed and
implemented by the Entity Institutes of Public Health (FBiH Public Health
Institute, Public Health Institute of the Republic of Srpska), in cooperation
with the Ministry of Health of entities and in cooperation with WHO coun-
try office in Bosnia and Herzegovina, which was jointly supported by the
Swiss Agency for Development and Cooperation (SDC) and World Health
Organization (WHO). (48)
Within component 2 of the Project entitled: Adaptation/development of
instruments, materials and indicators sets for implementing, controlling and
evaluating interventions in the field of cardiovascular risk assessment and
management (CVRAM), guidelines for prevention and control of CVD risk
factors were published in BiH, modeled after European Guidelines on cardio-
vascular disease prevention in clinical practice (version 2012) published by
European Society on Cardiovascular Prevention and Rehabilitation (EACPR).
Representatives of the Association of Cardiologists of Bosnia and
Herzegovina (member of the European Society of Cardiology ESC) took part
in the preparation of the guide.
A two-day CVRAM training program on using guidelines for prevention
and control of cardiovascular risk was completed during 2018, having tar-
geted 70% of all family medicine teams in Bosnia and Herzegovina. In total,
2624 family medicine professionals (1022 doctors (39%) and 1602 nurses
(61%)) was educated. An estimated 67.6% of the population of Bosnia and
Herzegovina (54.6% of the Brcko District of Bosnia and Herzegovina, 64.4% of
the Republic of Srpska and 70% of the Federation of Bosnia and Herzegovina)
now have access to standardized health care service for prevention, treatment,
CHAPTER III
and control of cardiovascular disease thanks to CVRAM training program on

using guidelines for prevention and control of cardiovascular risks. (48)
Monitoring and evaluation of the usage of guidelines by family medicine
teams in BiH included by the CVRAM training program was performed by
the entity agencies for accreditation and quality improvement in health care
before and after training programs were completed.
Subject of evaluation was agreed minimum set of 13 structure, process
and clinical outcomes indicators that are not routinely collected and reported
by family medicine teams, with the aim of obtaining information on the need
for further revision and improvement of accreditation standards for family
medicine teams in Bosnia and Herzegovina. (48)
The following guides and guidelines for family medicine teams have been
prepared and published in FBiH as a part of the same Project:
Guides:
• Prevention of cardiovascular disease: guidelines for assessment and man-
agement of total cardiovascular risk (SCORE),
• Hypertension Guide,
• Dyslipidemia Guide.
Guidelines:
• Guidelines for prevention and treatment of obesity in children and
adolescents,
• Guidelines for prevention and treatment of obesity in adults,
• Physical activity promotion guidelines,
• Guidelines for prevention and treatment of diabetes and cardiovascular
diseases,
• Smoking cessation guidelines.
FBiH Public Health Institute organized 61 workshops in community
health centers in FBiH which included 430 family medicine teams.
In total, 1122 doctors and nurses/technicians from family medicine teams
in FBiH completed the course on the use of guidelines. Educational centers
for family medicine teams in community health centers in Sarajevo, Mostar,
Tuzla, Zenica, and Bihać were included in training programs. (48)
WHO SCORE tables for calculating 10-year risk of CVD is based on the
correlation of age, sex, systolic blood pressure (mm Hg) and total cholesterol
(mmol/L).
Increased risk is recorded in patients who are smokers, obese, patients

with family history of premature CVD, low HDL cholesterol or high triglyc-
eride levels and patients with diabetes. (Figure 1)
Figure 1: WHO SCORE table of risk factors for CVD in BiH, 2012
This table is used to calculate the 10-year risk of fatal CVD for each per-
son in relation to sex, smoking status, age, systolic blood pressure (mm Hg)
and total cholesterol (mmol/l or mg/dl).
It represents a good mechanism for advising patients on the necessary
behavior changes, with low-risk patients being advised to maintain their low-
risk status, while those with a 5% or higher risk, or those who will reach that
risk in middle age, require adequate supervision. To define patient’s relative
risk their risk category should be compared with that of non-smokers of the
same age and sex, with blood pressure values below 140/90 mmHg and cho-
lesterol values less than 5 mmol/l. (190 mg/dl).
CHAPTER III
High-risk patients are those whose 10-year risk exceeds 15%. High-risk
groups include patients with pre-existing CVD and diabetics. Women with
diabetes have 5 times higher risk, and men with diabetes have 3 times higher
risk than the one set in the table. The risk is higher in persons living sedentary
lifestyle, as well as in persons with abdominal obesity, a family history of
early CVD and in socially disadvantaged persons.
Based on the proven significance of individual risk factors for the de-
velopment of cardiovascular diseases, a term “cardiovascular risk age” was
introduced and it is defined as the age of a person with several CVD risk fac-
tors that corresponds to the chronological age of a person with the same level
of total risk but ideal levels of CVD risk factors. An example is given of a
40-year-old smoker who has a total cholesterol level of 8 mmol/L, a systolic
blood pressure of 160 mmHg and his total cardiovascular risk is 3% accord-
ing to the SCORE table (absolute risk), which corresponds to the cardiovas-
cular risk age of a 60-year-old who has ideal levels risk factors (non-smoker,
normal cholesterol levels) (Figure 1).
Based on the obtained values of individual risk factors from the WHO’s
SCORE table and the analysis of their interaction, risk level for developing
CVD can be determine for each patient. (Figure 2)
Other risk factors Blood pressure

asymptomatic organ
damage or disease Elevated normal BP Level I HT Level II HT Level III HT
Without other RF x Low risk Moderate risk High risk
Moderate to high
1-2 RF Low risk Moderate risk High risk
risk
Low or moderate Moderate to high
≥3 RF High risk High risk
risk risk
Moderate to high High to very high
OD, CKD or DM High risk High risk
risk risk
Symptomatic CVD; CKD
phase ≥4 or DM with Very high risk Very high risk Very high risk Very high risk
OD/RF
Figure 2: Categorization of multiple CVD risk factors
BP = blood pressure; CV = cardiovascular; CVD = cardiovascular diseases; CKD = chronic kidney
disease; DBP = diastolic blood pressure; HT=hypertension; OD = organ damage; RF = risk factor;
SBP = systolic blood pressure.
Depending on patient’s CVD risk level, the type of necessary intervention

is determined: treatment or behavioral change. (Figure 3)
Recommendations Class Ia Levelb,c Levelb,d

Reducing salt intake to 5-6g per day I A B
Moderate alcohol consumption of no more than 20-30 g of ethanol per
I A B
day for men and no more than 10-20 g of ethanol per day for women
Increased consumption of vegetables, fruits and dairy products with
I A B
reduced fat content
Weight reduction so that BMI <25 kg / m2 and waist circumference <102
I A B
cm in men and <88 cm in women, unless contraindicated.
Physical activity, i.e., at least 30 minutes, moderately dynamic exercises
I A B
5-7 days a week
Advice to all smokers to quit smoking and offer them professional help. I A B
Figure 3: Recommended behavior changes according to the categorization
of evidence of CVD risk factors
a
Class of recommendation; bLevel of evidence; cBased on the effects of BP and/or CV risk profile,
d
Based on outcome studies
ESC European Guidelines on CVD prevention in clinical practice were

published in 2016 by WHO in which a revised SCORE table for CVD risk fac-
tors for certain parts of WHO region was done. In this revised version, Bosnia
and Herzegovina was placed among Central European countries. (25, 26)
To assess the overall cardiovascular risk, this document recommends
SCORE tables for population with low and/or high cardiovascular risk, esti-
mating the 10-year risk of fatal CVD in relation to the values of the following
risk factors: age, sex, smoking status, systolic blood pressure, total choles-
terol and HDL cholesterol levels. Bosnia and Herzegovina was classified as
high-risk country. (Figure 4)
CHAPTER III
Figure 4: WHO SCORE table for CVD risk factor, ECS 2016
SCORE table from the 2012 ESC European Guidelines on cardiovascu-

lar disease has been modified to consider the HDL cholesterol level, which
made it more accurate. The advantage of 2016 risk assessment SCORE table
is multifactorial scope of CVD risk factors, and the disadvantage is small age
range (40–65) and lack of adaptability to other ethnic groups within low and
high-risk population. (Figure 5)
Figure 5: CVD risk non-laboratory-based SCORE table, ECS 2016

Source: https://www.who.int/docs/default-source/cardiovascular-diseases/central-europe.
pdf?sfvrsn=5d127541_2
CHAPTER III
The risk for developing CVD can be categorized into four levels: low,
moderate, high and very high risk, and it depends on the number and severity
of risk factors, prior cardiovascular and blood vessel diseases, target organ
damage in diabetes and values from SCORE table. (25, 26). (Table 6)
Table 6. Cardiovascular risk categories, ECS, 2016
Level of risk SCORE value
Very high-risk SCORE >10%
• Documented CVD
• Diabetes mellitus type 1 or 2 with one or more CVD risk factors and/or target organ damage
• Chronic kidney disease (Glomerular filtration rate <30 mL/min/1,73 m2)
High-risk SCORE > 5 < 10%
• Elevated values of single risk factors
• Diabetes mellitus type 1 or 2 without CVD risk factors or target organ damage
Moderate risk SCORE > 1 < 5%
Low-risk SCORE < 1%
Source: ECS, 2016. god.
Interpretation of SCORE results:

• Low- to moderate-risk persons (calculated SCORE <5%) should be of-
fered lifestyle advice to keep their low- to moderate-risk status.
• High-risk persons (calculated SCORE ≥5% and <10%) qualify for inten-
sive lifestyle advice and may be candidates for drug treatment.
• Very-high-risk persons (calculated SCORE ≥10%) drug treatment is more
frequently required.
Total absolute risk estimation using SCORE tables is recommended for

all men over the age of 40 and women over the age of 50 (or earlier if they
entered postmenopausal period before that age) to be repeated every 4 to 5
years. Risk estimation is not recommended for people with high and very
high cardiovascular risk, but an immediate intervention is required.
Using SCORE tables to estimate total cardiovascular risk for younger in-
dividuals (under 40 years of age) may “downplay” the effect of individual
risk factors for cardiovascular disease, so younger people are advised to use
special relative risk table. (Figure 6).
Figure 6: 10-year relative risk of fatal CVD ECS, 2016

Source: ECS, 2016
Conclusions
Since Bosnia and Herzegovina does not have a single register for CVD, moni-
toring is done by analyzing data collected through regular statistical evidence
and periodic population surveys.
According to available data, leading cause of death in Bosnia and
Herzegovina are circulatory system diseases, dominated by acute myocardial
infarction (I20), stroke (I63), essential hypertension (I10), chronic ischemic
heart disease (I25) and cardiomyopathy (I42).
High CVD mortality rate in Bosnia and Herzegovina is associated with
an unfavorable trend of exposure to various risk factors, among which hy-
pertension, smoking, alcohol use, poor-quality diet and physical inactivity
dominate.
Relevant sources of good practice indicate that the most effective form
of preventive action in relation to CVD is a combination of population-wide
and individual approach. Population-wide approach target people with low
or medium CVD risk, while the individual approach target people with high
CVD risk.
Combining individual and population-wide interventions to prevent and
control risk factors for CVD should be a lifelong approach, from the very
beginning throughout the life cycle, because both risks and development of
CVD is a dynamic phenomenon associated with changeable and unchange-
able risk factors and/or accumulation of multiple diseases or comorbidities.
CHAPTER III
In the period from 2016 to 2017, the project “Strengthening and Improving
Modern and Sustainable Public Health Strategies, Capacities and Services
for Improving the Health of the Population in Bosnia and Herzegovina”
was launched in partnership with the Swiss Agency for Development and
Cooperation (SDC) and World Health Organization (WHO).
Through component 2 of this Project, titled: “Adjustment/ development
of instruments, materials and sets of indicators for implementation, monitor-
ing and evaluation of interventions from the domain of risk assessment and
CVD management (CVRAM), guidelines for prevention and control of CVD
risk factors were published in BiH by Public Health Institutes of both entities
with the support of Ministries of Health of both entities and modeled after
European Guidelines on cardiovascular disease prevention in clinical practice
(version 2012) published by European Society on Cardiovascular Prevention
and Rehabilitation (EACPR).
It is estimated that thanks to CVRAM training on the use of guidelines for
CVD prevention and control, around 67.6% of the population of Bosnia and
Herzegovina has access to standardized health services for prevention, treat-
ment and control of cardiovascular disease, of which 70% are citizens of the
Federation of BiH, 64.4 % citizens of Republic of Srpska and 54.6% citizens
of Brčko District.
Since WHO published ECS European Guidelines on cardiovascular dis-
ease prevention in clinical practice in 2016 in which a revised SCORE ta-
ble for CVD risk factors for certain parts of WHO region from 2012 was
done, it is necessary to do the correction of the CVD guidelines in Bosnia and
Herzegovina in accordance with this document.
CVD risk factors prevention must be an integral part of every health ser-
vice at all levels of health care. Special importance should be given to the
extensive use of standardized ESC guidelines on good practice which provide
the basis for systematic monitoring of risk factors, categorization of patients
according to SCORE risk level and selection of adequate medication and oth-
er interventions.
With the aim of reducing incidence and mortality of CVD in Bosnia and
Herzegovina, systematic support to the long-term public health intervention
to prevent CVD at the population level is needed through various long-term
intersectoral measures such as: promotion of healthy diet tailored to the needs
of population groups, promotion of smoke-free areas, promotion of physical
activity, adequate tax and price policies for tobacco and alcohol products in
Bosnia and Herzegovina and directing part of the funds collected from the tax
to finance interventions for prevention of CVD risk factors and promotion of

health, setting health warnings on food items and reaching an agreement with
the industry on reducing salt, fat and sugar intake, banning advertisement and
promotion of tobacco and alcohol products, and revising curriculum of all
educational institutions in Bosnia and Herzegovina to include more hours of
physical and health education classes.
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Chapter III

RISK FACTORS FOR CARDIOVASCULAR DISEASES

Prof. Aida Ramić-Čatak MD, PhD

recommendations were given to member states on the method for estimating

Cardiovascular disease as a global and regional challenge

Risk factors for the development of cardiovascular diseases

Modifiable CVD risk factors:

Harmful chemicals in cigarette smoke significantly accelerate the devel-

High blood cholesterol

High blood pressure – hypertension

Obesity and overweight

Non-modifiable risk factors

such as obesity, hypertension, hyperlipoproteinemia, and elevated fibrinogen

Other risk factors

Prevention of cardiovascular diseases (CVD)

Prevention of CVD is defined as a coordinated pool of activity at the

European Society of Cardiology (ESC) defines prevention of cardiovas-

Preventative and therapeutic interventions of CVD at individual

Systematic CVD risk assessment is recommended in people with high

It is recommended to repeat CVD risk assessment every five years,

Tabela 2. Preporuke za zdravu ishranu, ECS, 2016. god.

Regarding the treatment of hypertension as one of the leading risk factors

According to the European Society of Cardiology (ESC), guidelines for

Table 4: Recommendations for treatment of cardiovascular risk (SCORE) with regard to

The ESC Guidelines for CVD prevention emphasize the importance of

Population-level CVD preventive interventions

Legislation restricting child-centered marketing is also recommended -

In order to eliminate tobacco advertising, it is recommended that a com-

Cardiovascular disease in Bosnia and Herzegovina

Mortality rate from CVD in the Federation of Bosnia and

Source: FBiH Public Health Institute, 2020

Source: FBiH Public Health Institute, 2020

Source: FBiH Public Health Institute, 2020

The leading cause of death among men is acute myocardial infarction

Source: Public Health Institute of the FBiH, 2020

Risk factors for development of CVD in the FBiH

almost quarter of school-aged children or 24,4% currently use some tobacco

Prevention and control of CVD in Bosnia and Herzegovina

Federation of Bosnia and Herzegovina

comprehensive protection oriented at prevention, control and early diagnosis

• Policy and Strategy for Protection and Promotion of Mental Health in

Public health interventions in prevention and control of CVD

and control of cardiovascular disease thanks to CVRAM training program on

Increased risk is recorded in patients who are smokers, obese, patients

Other risk factors Blood pressure

Depending on patient’s CVD risk level, the type of necessary intervention

Recommendations Class Ia Levelb,c Levelb,d

ESC European Guidelines on CVD prevention in clinical practice were

SCORE table from the 2012 ESC European Guidelines on cardiovascu-

Figure 5: CVD risk non-laboratory-based SCORE table, ECS 2016

Interpretation of SCORE results:

Total absolute risk estimation using SCORE tables is recommended for

Figure 6: 10-year relative risk of fatal CVD ECS, 2016

to finance interventions for prevention of CVD risk factors and promotion of

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